UNITED STATES FIRE INSURANCE COMPANY THE NORTH RIVER INSURANCE COMPANY 305 MADISON AVENUE, MORRISTOWN, NJ 07962 NEW YORK LAWYERS PROFESSIONAL LIABILITY APPLICATION NOTICE: COVERAGE FOR WHICH THIS APPLICATION IS MADE IS WRITTEN ON A CLAIMS MADE BASIS MEANING, EXCEPT AS OTHERWISE PROVIDED, COVERAGE APPLIES ONLY TO CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, ARISING FROM PROFESSIONAL SERVICES RENDERED ON OR AFTER THE PRIOR ACTS DATE, IF ANY. COVERAGE FOR WHICH THIS APPLICATION IS MADE WILL INCLUDE AN AUTOMATIC AND NON-CANCELABLE SIXTY DAY EXTENDED REPORTING PERIOD TO REPORT CLAIMS. ALL COVERAGE UNDER THE POLICY WILL CEASE UPON THE TERMINATION OF THE POLICY, EXCEPT FOR THE AUTOMATIC EXTENDED REPORTING PERIOD COVERAGE, UNLESS THE INSURED PURCHASES ADDITIONAL OPTIONAL EXTENDED REPORTING PERIOD COVERAGE. OPTIONAL EXTENDED REPORTING PERIODS OF 12 MONTHS, 36 MONTHS, 72 MONTHS AND AN UNLIMITED PERIOD ARE AVAILABLE UPON PAYMENT OF AN ADDITIONAL PREMIUM. DURING THE FIRST SEVERAL YEARS OF THE CLAIMS- MADE RELATIONSHIP, CLAIMS-MADE RATES ARE COMPARATIVELY LOWER THAN OCCURRENCE RATES, AND THE INSURED CAN EXPECT SUBSTANTIAL ANNUAL PREMIUM INCREASES, INDEPENDENT OF OVERALL RATE LEVEL INCREASES, UNTIL THE CLAIMS-MADE RELATIONSHIP REACHES MATURITY. CAREFULLY READ THE ENTIRE POLICY FOR WHICH THIS APPLICATION IS MADE. WORDS AND PHRASES WHICH ARE PRINTED IN BOLD ITALIC TYPEFACE HAVE SPECIFIC MEANING AND ARE DEFINED IN SECTION IV OF THE POLICY. THE APPLICATION, ITS ATTACHMENTS AND ALL PREVIOUS APPLICATIONS AND THEIR ATTACHMENTS SHALL SERVE AS THE BASIS OF THE POLICY, AND SHALL BECOME PART OF SUCH POLICY SHOULD A POLICY BE ISSUED, AS IF PHYSICALLY ATTACHED. THE INSURER RELIES UPON THE APPLICATION IN ISSUING THE POLICY. COMPLETION OF THIS APPLICATION DOES NOT IN ANY WAY IMPLY SUCH COVERAGE UNDER THE POLICY. COVERAGE IS AFFORDED ONLY IF AND TO THE EXTENT INDICATED BY THE TERMS AND CONDITIONS OF THE POLICY IF ISSUED. YOU MAY ELECT TO PURCHASE COVERAGE WITH DEFENSE EXPENSES WITHIN THE LIMIT OF LIABILITY. IF YOU ELECT TO PURCHASE THIS COVERAGE, DEFENSE EXPENSES SHALL REDUCE AND MAY EXHAUST THE LIMIT OF LIABILITY. THE COMPANY WILL NOT BE OBLIGATED TO PAY ANY JUDGMENTS, AWARDS, SETTLEMENTS OR DEFENSE EXPENSES AFTER THE LIMIT OF LIABILITY HAS BEEN EXHAUSTED. YOU MAY ELECT TO PURCHASE COVERAGE CONTAINING A DEFENSE EXPENSE COST OFFSET FOR THE LIMIT OF LIABILITY. IF YOU ELECT TO PURCHASE THIS COVERAGE, UP TO 50% OF THE LIMIT OF LIABILITY MAY BE USED FOR DEFENSE EXPENSES AND ANY DEFENSE EXPENSES THAT EXCEED THIS AMOUNT THEREAFTER SHALL BE IN ADDITION TO THE LIMIT OF LIABILITY. YOU MAY ELECT TO PURCHASE COVERAGE WITH DEFENSE EXPENSES SUBJECT TO THE EACH CLAIM DEDUCTIBLE. YOU MAY ELECT TO PURCHASE COVERAGE WITH DEFENSE EXPENSES SUBJECT TO THE AGGREGATE DEDUCTIBLE. YOU MAY ELECT TO PURCHASE COVERAGE CONTAINING A DEFENSE EXPENSE COST OFFSET FOR THE EACH CLAIM DEDUCTIBLE. IF YOU ELECT TO PURCHASE THIS COVERAGE, NO MORE THAN 50% OF THE EACH CLAIM DEDUCTIBLE WILL BE SUBJECT TO DEFENSE EXPENSES. YOU MAY ELECT TO PURCHASE COVERAGE CONTAINING A DEFENSE EXPENSE COST OFFSET FOR THE AGGREGATE DEDUCTIBLE. IF YOU ELECT TO PURCHASE THIS COVERAGE, NO MORE THAN 50% OF THE AGGREGATE DEDUCTIBLE WILL BE SUBJECT TO DEFENSE EXPENSES. UNLESS AMENDED BY ENDORSEMENT, AMOUNTS INCURRED AS DEFENSE EXPENSES SHALL BE IN ADDITION TO THE LIMIT OF LIABILITY AND SHALL NOT BE SUBJECT TO THE DEDUCTIBLE. Wherever the word Applicant is used, it will be deemed to include all attorneys within the firm and any predecessor firms. 1. Firm Name: Legal name of the Applicant to be insured Address: Principal location City: State: Zip: Firm Phone Number: E-mail Address: County: Contact Name: 2. Desired Effective Date: / / MM / DD / YYYY 3. What year was the Applicant firm established? NYLPL 101 (04/11) Page 1 of 6
4. Indicate number of attorneys employed by firm: Please list all attorneys on the Addendum on Page 6. 5. What is the number of non attorney support staff (full and part time combined)? 6. Does the Applicant have offices other than the principal location indicated in question 1? a. If, provide the following information for these additional offices from where you practice: Name of Firm Address City State Zip # of Attorneys # of other Employees % of Firm s Billable Hours b. Does the responsibility for the Applicant s other offices rest with management at the principal location? If, please describe how the branch office operates and is managed: 7. Is the Applicant s office or suite shared with attorneys who are not members of the Applicant s firm? 8. Are there any other legal entities under which the Applicant provides legal services? If please list: 9. Gross fees billed by the Applicant for the last 2 years: Most Current Completed Year FYE: / MM / YYYY Prior Year FYE: / MM / YYYY $ $ 10. Does the Applicant have public figures as clients (e.g. Entertainment, Politics or Sports)? If please complete the Public Figure Supplement. 11. At any time in the past five years, has the Applicant or any attorney of the Applicant (regardless of what firm the attorney was employed by at such time) provided legal services related to mass tort/class action, securities transactions, investment vehicles or ventures, money or investment management or investments with clients? If please identify and explain the relevant legal services. 12. Does anyone affiliated with the Applicant maintain any equity interest in a Title Insurance Agency? NYLPL 101 (04/11) Page 2 of 6
13. Enter the percentage of billable hours for each area below in the past fiscal year. Indicate percentages in whole numbers next to the type of law the Applicant practices (Must include all entities listed in 6.a.): AREA OF PRACTICE % OF REVENUE AREA OF PRACTICE % OF REVENUE A. Admiralty / Marine % Q. Investment Counseling / Money Mgt. % B. Banking / Financial Institution (1) % R. International Law % C. Anti-trust/Trade Regulation % S. Natural Resources / Oil & Gas % D. Arbitration % T. Personal Contracts % E. Collection/Bankruptcy (2) % U. Plaintiff Litigation (5) % F. Civil Rights/Employment % V. Public Utilities % G. Corporate Business Organization % W. Real Estate Commercial (6) % H. Copyright/ Trademark /Patent (3) % X. Real Estate Residential (7) % I. Defense / Criminal Litigation % Y. Securities/Bonds (8) % J. Domestic Relations % Z. Tax (9) % K. Elder Law % AA. Title Opinions % L. Entertainment % BB. Wills, Trusts, Estates (10) % M. Environmental (4) % CC. Other (please describe): N. ERISA / Pensions % % O. Government % % P. Immigration % TOTAL (must equal 100%) % If the Applicant practices in any area(s) above with a numerical notation(s), complete the associated Supplement as follows: (1) Banking / Financial Institution (2) Collections / Bankruptcy (3) Copyright/Trademark/Patent (4) Environmental NYLPL 101 (04/11) Page 3 of 6 (5) Plaintiff Litigation (6) Real Estate Commercial (7) Real Estate Residential (8) Securities/Bonds 14. At any time during the last 3 years has any client of the Applicant represented more than 25% of the Applicant s annual revenue? (9) Tax (10) Wills, Trusts, Estate a. If, please indicate percentage of revenue from largest revenue client (include client s affiliated entities): % Services rendered: One Time Judgment or Settlement Agreement Relationship of 3 or more years b. Please indicate the percentage of revenue from second largest revenue client (include client s affiliated entities): % Services rendered: One Time Judgment or Settlement Agreement Relationship of 3 or more years 15. Does the Applicant have a policy prohibiting an attorney with an investment in a client from working on transactions of such clients? 16. Does the Applicant have any clients in which its attorneys have a combined equity interest greater than 10%? 17. In the past 5 years, has the Applicant or its personnel served as an officer, director, partner, manager, employee, committee member of any client? If to question 16 or 17 please complete the information below: Attorney Name Entity Name Nature of Client Business Position Held Percent of Firm s Billings Percent Equity Interest Service Provided by Firm Does the individual listed perform these services? Is Director / Officer Insurance in force?
18. Do all attorneys follow established procedures for identifying and resolving potential or actual conflicts of interest including cross checking of former, existing or potential clients? 19. Does the Applicant maintain a central docket control or diary system? 20. Does the Applicant use engagement letters including fee agreements on all new matters undertaken by the firm? 21. Are declinations or non-engagement letters, which include time sensitive dates, issued on all matters declined by the Applicant? 22. Does Applicant have procedures which address the conduct of employees relative to the handling of confidential information of clients? 23. What percentage of Applicant s accounts receivable is outstanding more than 90 days? % 24. In the last 5 years has the Applicant initiated lawsuits or arbitration procedures to enforce the collection of unpaid fees of any client? If, please complete the Fee Suit Supplement CLAIM / INCIDENT INFORMATION 25. After inquiry of all attorneys of the Applicant, within the past 5 years have any past or present attorneys: a. been the subject of any disciplinary proceeding, regulatory investigation or inquiry; suspended from practice; or charged,indicted, pled no contest ( nolo contendere ) or pled guilty to a civil or criminal charge relating to the practice of law? If yes, please provide details and dates: b. know of any professional liability claims made against the Applicant, its affiliates or its lawyers? c. had any reasonable basis to believe that an act or omission in the rendering of professional services might become the basis of a claim against the Applicant or the Applicant s predecessor(s), regardless of whether you would deem such a claim to be meritorious? NOTE: THE POLICY FOR WHICH THIS APPLICATION IS BEING MADE SHALL NOT APPLY TO ANY INCIDENTS OR CLAIMS DETAILED OR WHICH SHOULD HAVE BEEN DETAILED IN THE QUESTION 25 a, b or c ABOVE. If to 25. b. or c. above, complete the CLAIM SUPPLEMENT for each claim or potential claim 26. Within the past five years has the Applicant or its attorneys been declined, canceled, or non-renewed for professional liability insurance for any reason? If, please provide dates and reasons: PRIOR INSURANCE INFORMATION 27. Does Applicant currently carry professional liability insurance? If, provide the information requested below: Insurance Company(not broker/agent): Limits of Liability: $ Defense expenses reduce limits of liability Policy Expiration Date: / / MM / DD /YYYY OR Defense expenses are paid in addition to limits of liability Deductible: $ Per Claim OR Annual Aggregate Deductible does not apply to defense expenses (first dollar defense) Indicate the prior acts date (also known as retroactive date) for your policy: Prior Acts Date / / Premium: $ MM / DD / YYYY 28. Does the policy above include lateral hire coverage for any of the Applicant s current attorneys? 29. Does the policy above, exclude coverage for any attorney, predecessor firms, firm affiliates, clients, specific engagements or other circumstances? If, please describe: NYLPL 101 (04/11) Page 4 of 6
COVERAGE SELECTION Indicate your desired coverage selection: 30. Limits of Liability: $ / per claim / aggregate Defense expenses reduce limits of liability OR Defense expenses are paid in addition to limits of liability 31. Deductible: $ Per Claim OR Annual Aggregate Deductible does not apply to defense expenses (first dollar defense) 32. Have you acquired or merged with another firm in the past 10 years? a. If, was the Applicant the majority successor in interest to the financial assets and liabilities of the acquired or merged firm? b. If, does the Applicant desire coverage for this entity as a predecessor firm? If to b. above complete the Predecessor Firm Supplement. Completion and/or signing of this application does not bind the Applicant to purchase, nor the Insurer to provide, any insurance policy; however, no policy can be issued unless the application is properly completed, signed and dated. The signatory declares that (s)he is authorized by the Applicant to sign this application on behalf of all prospective Insureds and that to the best of his/her knowledge the statements herein are true. The signatory agrees that if the information supplied in this application and the materials submitted therewith should change between the date this application is signed and the effective date of the proposed insurance, the signatory shall immediately notify the Insurer of such and shall provide the Insurer with information that would complete, update or correct the application or materials submitted therewith. The Insurer may withdraw or modify any of the terms or conditions of coverage accordingly. ALL WRITTEN STATEMENTS, SUPPLEMENTAL APPLICATIONS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART THEREOF, AND DEEMED ATTACHED HERETO. NOTICE TO NEW YORK APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION." SIGNATURE* PRINTED NAME* *MUST BE SIGNED BY A DULY AUTHORIZED OFFICER OF THE APPLICANT ON BEHALF OF ALL INSUREDS. TITLE OF SIGNATORY: DATE SIGNED: / / MM / DD / YYYY PLEASE ATTACH TO THIS APPLICATION A SAMPLE OF ALL LETTERHEADS USED BY THE FIRM. NYLPL 101 (04/11) Page 5 of 6
ADDENDUM TO LAWYERS PROFESSIONAL LIABILITY APPLICATION LIST OF ALL ATTORNEYS EMPLOYED BY APPLICANT (please attach additional sheets as necessary) List all of the Applicant s attorneys below: Attorney Name *Attorney Designation State(s) Licensed to Practice Law Annual Hours Worked Date Joined the Firm # of Years in Practice Years of Continuous Professional Liability Coverage *Attorney Designations: A = Associate, E = Employee, IC = Independent Contractor, OC = Of Counsel, P = Partner, RP = Retired Partner NYLPL 101 (04/11) Page 6 of 6